MRD officer

Role & responsibilities

Management of Medical Records

• Maintain and manage

  patient medical records

  ensuring accuracy, completeness, and confidentiality.
• Organize and file medical records systematically for easy retrieval.
  
• Ensure all medical records are updated timely with relevant clinical notes, reports, test results, and discharge summaries.
  
• Manage both

  paper-based

  and

  electronic health records (EHRs)

  efficiently.

Coding and Classification

• Supervise or assist with

  medical coding

  (ICD-11, CPT) to classify diagnoses and procedures accurately.
• Ensure coding aligns with

  hospital billing and insurance requirements

  .
• Coordinate with the billing and insurance departments to resolve discrepancies related to coding.
  

Data Accuracy and Quality Control

• Conduct

  periodic audits

  of medical records to maintain data integrity and compliance with regulatory standards (NABH, ISO, JCI).
• Identify and rectify errors, missing information, or discrepancies in patient files.
  
• Ensure compliance with

  legal and ethical standards

  governing patient data privacy (e.g., HIPAA-like rules).

Reporting & Documentation

• Prepare and submit periodic reports on medical records activities to hospital administration.
  
• Provide statistical data and analysis related to patient admissions, discharges, morbidity, and mortality for research and management purposes.
  
• Maintain records of medical records personnel attendance, performance, and training.
  

Supervision and Training

• Supervise Medical Records Department (MRD) staff including coders, record technicians, and clerks.
  
• Conduct or arrange training programs to update staff on new coding standards, software, and regulatory changes.
  
• Ensure smooth workflow and task delegation in the MRD.
  

Coordination

• Coordinate with clinical departments, nursing, billing, and IT teams for smooth exchange of medical information.
  
• Support medical audit and research activities by providing required data and documentation.
  
• Liaise with external bodies for compliance, accreditation, and legal matters related to medical records.
  

System Maintenance and Upgradation

• Assist in implementing and upgrading Hospital Information Systems (HIS) and Electronic Medical Records (EMR) systems.
  
• Facilitate smooth migration of paper records to digital formats when applicable.
  
• Ensure backup and disaster recovery procedures for medical records.
  

Compliance and Confidentiality

• Maintain strict confidentiality and safeguard patient privacy at all times.
  
• Ensure adherence to hospital policies and governmental laws related to health information management.